Although it is rare for cardiovascular disease (CVD) to manifest in children and adolescents, risk factors and behaviors do start in childhood. Evidence indicates that reducing risk can slow the progression of CVD; therefore, the National Heart, Lung, and Blood Institute (NHBLI) Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents developed guidelines to help health care professionals promote cardiovascular health and to identify and manage risk factors in children and adolescents. These guidelines were based on evidence that atherosclerosis begins, and its risk factors can be identified, in childhood; that atherosclerosis development and progression are associated with these risk factors; that risk factors track from childhood into adulthood; and that there are options for managing these risk factors.

Prevention goals in young persons should be separate from prevention goals in older persons in whom atherosclerosis is well established. Historically, preventing the development of risk factors and preventing CVD through effective management of risk factors have been the two main goals in young persons. Research supports the theory that childhood populations with lower levels of cardiovascular risk factors will have less atherosclerosis and CVD as adults.

Integrated Cardiovascular Health Schedule

Risk factor

Age

Birth to 12 months

1 to 4 years

5 to 9 years

9 to 11 years

12 to 17 years

18 to 21 years

Family history of early CVD

—

At 3 years, evaluate family history for early CVD: parents, grandparents, aunts/uncles, men ≤ 55 years, women ≤ 65 years; review with parents and refer as needed; positive family history identifies children for intensive CVD risk factor attention

Update at each nonurgent health encounter

Reevaluate family history for early CVD in parents, grandparents, aunts/uncles, men ≤ 55 years, women ≤ 65 years

Support breastfeeding as optimal to 12 months of age if possible; add formula if breastfeeding decreases or stops before 12 months of age

At age 12 to 24 months, may change to cow's milk with 2% fat decided by family and children's health care professional; after 2 years of age, fat-free milk for all; juice ≤ 4 oz per day; transition to CHILD-1* by 2 years of age

Reinforce CHILD-1* messages

Reinforce CHILD-1* messages as needed

Obtain diet information from child and use to reinforce healthy diet and limitations; provide counseling as needed

Review healthy diet with patient

Growth, overweight/obesity

Review family history for obesity; discuss weight-for-height tracking, growth chart, and healthy diet

Chart height/weight/BMI; classify weight by BMI from age 2 years; review with parent

*—Recommended intakes are adequately met by a DASH (dietary approaches to stop hypertension)–style eating plan, which emphasizes fat-free/low-fat dairy and increased intake of fruits and vegetables. This diet has been modified for use in children four years and older on the basis of daily energy needs according to food group.

Adapted with permission from National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011;128(suppl 5):S219.

Table 1.

Integrated Cardiovascular Health Schedule

Risk factor

Age

Birth to 12 months

1 to 4 years

5 to 9 years

9 to 11 years

12 to 17 years

18 to 21 years

Family history of early CVD

—

At 3 years, evaluate family history for early CVD: parents, grandparents, aunts/uncles, men ≤ 55 years, women ≤ 65 years; review with parents and refer as needed; positive family history identifies children for intensive CVD risk factor attention

Update at each nonurgent health encounter

Reevaluate family history for early CVD in parents, grandparents, aunts/uncles, men ≤ 55 years, women ≤ 65 years

Support breastfeeding as optimal to 12 months of age if possible; add formula if breastfeeding decreases or stops before 12 months of age

At age 12 to 24 months, may change to cow's milk with 2% fat decided by family and children's health care professional; after 2 years of age, fat-free milk for all; juice ≤ 4 oz per day; transition to CHILD-1* by 2 years of age

Reinforce CHILD-1* messages

Reinforce CHILD-1* messages as needed

Obtain diet information from child and use to reinforce healthy diet and limitations; provide counseling as needed

Review healthy diet with patient

Growth, overweight/obesity

Review family history for obesity; discuss weight-for-height tracking, growth chart, and healthy diet

Chart height/weight/BMI; classify weight by BMI from age 2 years; review with parent

*—Recommended intakes are adequately met by a DASH (dietary approaches to stop hypertension)–style eating plan, which emphasizes fat-free/low-fat dairy and increased intake of fruits and vegetables. This diet has been modified for use in children four years and older on the basis of daily energy needs according to food group.

Adapted with permission from National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011;128(suppl 5):S219.

Lipid and lipoprotein levels in childhood are predictive of levels in adulthood, with the strongest relationship occurring between levels in late childhood and at age 20 to 40 years. Table 2 lists normal lipid and lipoprotein distributions in children and adolescents. Total and low-density lipoprotein (LDL) cholesterol levels can decrease by 10 to 20 percent or more during puberty. Based on this, a stable time for lipid evaluation would be 10 years of age, which is before puberty in most children.

Acceptable, Borderline-High, and High Plasma Lipid, Lipoprotein, and Apolipoprotein Concentrations for Children and Adolescents

Category

Low (mg per dL)*

Acceptable (mg per dL)

Borderline-high (mg per dL)*

High (mg per dL)*

Total cholesterol

—

< 170

170 to 199

≥ 200

LDL cholesterol

—

< 110

110 to 129

≥ 130

Non-HDL cholesterol

—

< 120

120 to 144

≥ 145

Apolipoprotein B

—

< 90

90 to 109

≥ 110

Triglycerides

0 to 9 years of age

—

< 75

75 to 99

≥ 100

10 to 19 years of age

—

< 90

90 to 129

≥ 130

HDL cholesterol

< 40

> 45

40 to 45

—

Apolipoprotein A-1

< 115

> 120

115 to 120

—

note: Values for plasma lipid and lipoprotein levels are from the National Cholesterol Education Program Expert Panel on Cholesterol Levels in Children. Non-HDL cholesterol values from the Bogalusa Heart Study are equivalent to the National Cholesterol Education Program Pediatric Panel cut points for LDL cholesterol. Values for plasma apolipoprotein B and apolipoprotein A-1 are from the National Health and Nutrition Examination Survey III. Note that values shown are in mg per dL; to convert to SI units, divide the results for total cholesterol, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6.

HDL = high-density lipoprotein; LDL = low-density lipoprotein.

*—Low cut points for HDL cholesterol and apolipoprotein A-1 represent approximately the 10th percentile. The cut points for high and borderline-high represent approximately the 95th and 75th percentiles, respectively.

Adapted with permission from National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011;128(suppl 5):S237.

Table 2.

Acceptable, Borderline-High, and High Plasma Lipid, Lipoprotein, and Apolipoprotein Concentrations for Children and Adolescents

Category

Low (mg per dL)*

Acceptable (mg per dL)

Borderline-high (mg per dL)*

High (mg per dL)*

Total cholesterol

—

< 170

170 to 199

≥ 200

LDL cholesterol

—

< 110

110 to 129

≥ 130

Non-HDL cholesterol

—

< 120

120 to 144

≥ 145

Apolipoprotein B

—

< 90

90 to 109

≥ 110

Triglycerides

0 to 9 years of age

—

< 75

75 to 99

≥ 100

10 to 19 years of age

—

< 90

90 to 129

≥ 130

HDL cholesterol

< 40

> 45

40 to 45

—

Apolipoprotein A-1

< 115

> 120

115 to 120

—

note: Values for plasma lipid and lipoprotein levels are from the National Cholesterol Education Program Expert Panel on Cholesterol Levels in Children. Non-HDL cholesterol values from the Bogalusa Heart Study are equivalent to the National Cholesterol Education Program Pediatric Panel cut points for LDL cholesterol. Values for plasma apolipoprotein B and apolipoprotein A-1 are from the National Health and Nutrition Examination Survey III. Note that values shown are in mg per dL; to convert to SI units, divide the results for total cholesterol, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6.

HDL = high-density lipoprotein; LDL = low-density lipoprotein.

*—Low cut points for HDL cholesterol and apolipoprotein A-1 represent approximately the 10th percentile. The cut points for high and borderline-high represent approximately the 95th and 75th percentiles, respectively.

Adapted with permission from National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011;128(suppl 5):S237.

To reduce total and LDL cholesterol levels, children should eat a diet made up of 25 to 30 percent of calories from fat, with less than 10 percent from saturated fat, and less than 300 mg of cholesterol per day (e.g., CHILD-1 [cardiovascular health integrated lifestyle diet]). Some evidence indicates that this type of diet also reduces total and LDL cholesterol levels if started in infancy and continued through adolescence. A diet that has no more than 7 percent of calories from saturated fat and less than 200 mg of cholesterol per day (CHILD-2-LDL) has been shown to decrease LDL cholesterol levels in children diagnosed with hypercholesterolemia and an elevated LDL cholesterol level. Table 3 briefly summarizes the various recommended diets.

Pharmacologic treatment is limited to children with severe primary hyperlipidemia (homozygous familial hypercholesterolemia, primary hypertriglyceridemia*), a high-risk condition, or evident cardiovascular disease, all under the care of a lipid specialist

C; recommend

≥ 10 to21 years

Detailed family history and risk factor assessment required before initiation of drug therapy†

LDL cholesterol is 160 to 189 mg per dL with a positive family history or at least one high-level risk factor/condition or at least two moderate-level risk factors/conditions, consider statin therapy

B; recommend

LDL cholesterol ≥ 130 to 159 mg per dL and at least two high-level risk factors/conditions, or one high-level risk factor and two moderate-level risk factors/conditions, consider statin therapy

B; recommend

Children on statin therapy should be counseled and carefully monitored

A; strongly recommend

≥ 10 to 21 years

Detailed family history and risk factor/condition assessment required before initiation of drug therapy†¶

C; strongly recommend

Triglycerides:

If average triglycerides ≥ 500 mg per dL, consult lipid specialist

B; recommend

If average triglycerides ≥ 100 mg per dL in a child younger than 10 years, ≥ 130 mg per dL in a child 10 to 19 years of age, or < 500 mg per dL, refer to dietitian for medical nutrition therapy with CHILD-1,‡ then CHILD-2–TG** for 6 months

Children at least 10 years of age with non-HDL cholesterol ≥ 145 mg per dL after LDL cholesterol goal is achieved may be considered for additional treatment with statins, fibrates, or niacin in conjunction with a lipid specialist consultation

D; optional

note: Grades reflect the findings of the evidence review, and recommendation levels reflect the consensus opinion of the expert panel. When medication is recommended, it should always be in the context of the complete cardiovascular risk profile of the patient and in consultation with the patient and the family.

Evidence grading system:

A = Well-designed randomized controlled trials or diagnostic studies performed on a population similar to the guideline's target population.

†—Consideration of drug therapy is based on the average of at least two fasting lipid profiles, obtained at least 2 weeks but no more than 3 months apart.

‡—Recommended intakes are adequately met by a DASH (dietary approaches to stop hypertension)–style eating plan, which emphasizes fat-free/low-fat dairy and increased intake of fruits and vegetables. This diet has been modified for use in children four years and older on the basis of daily energy needs according to food group.

§—For children with elevated LDL cholesterol. Diet consists of 25 to 30 percent of calories from fat, no more than 7 percent from saturated fat, and approximately 10 percent from monounsaturated fat; less than 200 mg per day of cholesterol; and avoidance of trans fats.

||—If average LDL cholesterol ≥ 190 mg per dL after CHILD-2–LDL and child is 8 to 9 years of age with a positive family history or at least one high-level risk factor/condition or at least two moderate-level risk factors/conditions, statin therapy may be considered.

¶—If the child is obese, nutrition therapy should include calorie restriction and increased activity beyond that recommended for all children.

**—For children with elevated triglycerides or non-HDL cholesterol. Diet consists of 25 to 30 percent of calories from fat, no more than 7 percent from saturated fat, and approximately 10 percent from monounsaturated fat; less than 200 mg per day of cholesterol; avoidance of trans fat; decreased sugar intake; and increased fish intake (to increase omega-3 fatty acids).

Adapted with permission from National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011;128(suppl 5):S244.

Pharmacologic treatment is limited to children with severe primary hyperlipidemia (homozygous familial hypercholesterolemia, primary hypertriglyceridemia*), a high-risk condition, or evident cardiovascular disease, all under the care of a lipid specialist

C; recommend

≥ 10 to21 years

Detailed family history and risk factor assessment required before initiation of drug therapy†

LDL cholesterol is 160 to 189 mg per dL with a positive family history or at least one high-level risk factor/condition or at least two moderate-level risk factors/conditions, consider statin therapy

B; recommend

LDL cholesterol ≥ 130 to 159 mg per dL and at least two high-level risk factors/conditions, or one high-level risk factor and two moderate-level risk factors/conditions, consider statin therapy

B; recommend

Children on statin therapy should be counseled and carefully monitored

A; strongly recommend

≥ 10 to 21 years

Detailed family history and risk factor/condition assessment required before initiation of drug therapy†¶

C; strongly recommend

Triglycerides:

If average triglycerides ≥ 500 mg per dL, consult lipid specialist

B; recommend

If average triglycerides ≥ 100 mg per dL in a child younger than 10 years, ≥ 130 mg per dL in a child 10 to 19 years of age, or < 500 mg per dL, refer to dietitian for medical nutrition therapy with CHILD-1,‡ then CHILD-2–TG** for 6 months

Children at least 10 years of age with non-HDL cholesterol ≥ 145 mg per dL after LDL cholesterol goal is achieved may be considered for additional treatment with statins, fibrates, or niacin in conjunction with a lipid specialist consultation

D; optional

note: Grades reflect the findings of the evidence review, and recommendation levels reflect the consensus opinion of the expert panel. When medication is recommended, it should always be in the context of the complete cardiovascular risk profile of the patient and in consultation with the patient and the family.

Evidence grading system:

A = Well-designed randomized controlled trials or diagnostic studies performed on a population similar to the guideline's target population.

†—Consideration of drug therapy is based on the average of at least two fasting lipid profiles, obtained at least 2 weeks but no more than 3 months apart.

‡—Recommended intakes are adequately met by a DASH (dietary approaches to stop hypertension)–style eating plan, which emphasizes fat-free/low-fat dairy and increased intake of fruits and vegetables. This diet has been modified for use in children four years and older on the basis of daily energy needs according to food group.

§—For children with elevated LDL cholesterol. Diet consists of 25 to 30 percent of calories from fat, no more than 7 percent from saturated fat, and approximately 10 percent from monounsaturated fat; less than 200 mg per day of cholesterol; and avoidance of trans fats.

||—If average LDL cholesterol ≥ 190 mg per dL after CHILD-2–LDL and child is 8 to 9 years of age with a positive family history or at least one high-level risk factor/condition or at least two moderate-level risk factors/conditions, statin therapy may be considered.

¶—If the child is obese, nutrition therapy should include calorie restriction and increased activity beyond that recommended for all children.

**—For children with elevated triglycerides or non-HDL cholesterol. Diet consists of 25 to 30 percent of calories from fat, no more than 7 percent from saturated fat, and approximately 10 percent from monounsaturated fat; less than 200 mg per day of cholesterol; avoidance of trans fat; decreased sugar intake; and increased fish intake (to increase omega-3 fatty acids).

Adapted with permission from National Heart, Lung, and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: summary report. Pediatrics. 2011;128(suppl 5):S244.

In children with familial hypercholesterolemia, up to 20 g per day of a dietary supplement (e.g., plant sterol or stanol esters) can augment LDL cholesterol–lowering effects in the short term. Long-term trials have not been performed; therefore, these types of dietary supplements are typically used only for children in whom LDL cholesterol goals cannot be achieved with dietary therapy alone, with the hope that they may lower LDL cholesterol levels enough to avoid using medication. Consuming a diet with fewer simple carbohydrates (and with more complex carbohydrates and less saturated fat) and losing weight are associated with lower triglyceride levels. Children with elevated triglyceride levels and obesity should eat fewer calories, with the CHILD-2–TG being the recommended diet. It is also important that these children get more physical activity.

Table 3 provides the recommendations for pharmacologic treatment of dyslipidemia.